Information Collection

Individual Questionnaire

IC 223311 under ICR 201608-0920-013 · OMB 0920-1137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1137 can be found here:

Documents and Forms

Document Name Document Type
Individual Questionnaire Form and Instruction
Zika Investigation - Individual Interview Form SPANISH Att H - Individual questionnaire SPANISH.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Zika Investigation - Individual Interview Form SPANISH	Att H - Individual questionnaire SPANISH.doc	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0113 Epidemic Investigation Case Records Systems Notice	FR Citation: 51 FR 42466

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.